Freedman spoke May 2 alongside a panel of experts to discuss barriers to quality, rights-based maternal health services for women around the world.

“The issue of disrespect and abuse during childbirth may seem simple on the surface. However, it is deeply rooted in complexity,” said Kathleen McDonald, project manager for the Hansen Project on Maternal and Child Health at the Maternal Health Task Force. “It is not specific to South Asia, or sub-Saharan Africa, but rather disrespect and abuse are global issues that affect every health system in the world.”

Disrespect and Abuse

While progress has been made in increasing access to maternal health services, Millennium Development Goal 5 – reduce maternal mortality by three-quarters and achieve universal access to reproductive health – is not expected to be met. Part of the reason may be that disrespectful and abusive service drives women away from formal health care systems.

“The human rights argument in the public health field is commonly framed within the context of access to health care,” said Mande Limbu, the maternal health technical advisor at the White Ribbon Alliance. “But while access to health care is necessary for optimal maternity care, it is not sufficient. Disrespectful and abusive behavior happens even when women have free access to maternity care.”

“In Kenya, we are working in 13 private, public and faith-based facilities to gain a deeper story of women’s experiences,” said Charlotte Warren, an associate for the Population Council. To establish a clearer picture of maternal health care conditions, they surveyed women “from admission all the way through to post-natal care,” she said. The results were dramatic.

Warren reported that women were consistently subjected to non-confidential, non-consensual and non-dignified care. For example, Kenyan women recalled being scolded for screaming during childbirth, slapped by the medical staff and forced to walk around the ward naked. Further, only 38 percent of providers responded that women have the right to be informed of the procedures being performed and only 37 percent responded that information confidentiality was important.

“This is a problem that doesn’t belong to one country, to one region of the world, to one income level or to one particular population,” said Kathleen Hill, the senior technical advisor for USAID’s Translating Research into Action Project. “There were reports describing this from over 45 countries.”

According to Hill, there is suggestive evidence that disrespect and abuse deter women from utilizing institutional health services. In countries where traditional, often unskilled, health services offer a culturally acceptable alternative to the formal health sector, such mistreatment impedes the delivery of skilled birth services to women, she said.

“Some nurses rough you up to the extent that you tell her to let you deliver alone,” one Kenyan woman told Hill. “You are in pain and all she does is give you a harsh and rude approach. That is why I don’t go to the hospital to deliver, because I am not used to somebody who roughs me up.”

“If You Care for Nurses, They Will Care for Patients”

However, Hill cautioned against an oversimplified explanation of poor service, noting that abuse often arises when providers and staff are themselves feeling overwhelmed by workforce shortages, scarcities of essential supplies or a lack of promotional opportunities. “There are multiple points of suffering and complexity here,” she said.

“How do you expect a midwife to be in a good mood if she works with no breaks and has many clients to attend to in a dirty working environment?” asked Warren. These conditions lay the groundwork for disrespect and help explain why patient neglect is so prevalent, particularly in countries that lack enforceable national laws and oversight over health services, said Hill.

One Kenyan nurse told Hill, “by the ninth, tenth, eleventh delivery of the night, I would have been rated minus zero. If you care for the nurses, they will care for the patients.”

The Maternity Care Charter

In response to this data, the White Ribbon Alliance has implemented “policy and advocacy” interventions aimed at promoting respectful maternity care on a global level, said Limbu.

To improve the working conditions for staff, the alliance has conducted workshops in Uganda, Vietnam and Peru to empower midwives – often overworked under poor conditions – to advocate for themselves.

To develop a formal human rights mechanism that protects patients, the alliance convened a global and multi-sector community of concerned citizens, researchers and donors to develop the Respectful Maternity Care Charter in 2011. Using data obtained by the Population Council, TRAction Project, and others, the charter identifies seven universal rights that can be applied to national health care systems as a framework for better care.

“We have used the charter to demonstrate the legitimate place of maternal health rights within the broader context of human rights…to increase visibility so that we can raise the veil of silence around this issue,” said Limbu. For example, the White Ribbon Alliance is supporting campaigns in Nepal, Nigeria and Malawi advocating for the inclusion of the charter’s language in upcoming national legislation.

“In doing all this, we desire to see systemic changes that will affect policy, health systems and awareness to bring about improved maternal care,” said Limbu.